DISSOCIATIVE IDENTITY

DISORDER
PREPARED BY – DR MESKEREM ABEBE
MODERATOR –DR TIGIST ZERIHUNE
 OBJECTIVES
• Introduction to dissociative identity disorder
• Epidemiology
• Etiology
• Clinical features and diagnosis
• Differential diagnosis
• Course and prognosis
• Treatment
 Introduction

• It was previously called multiple personality disorder

• The most extensively researched of all the dissociative disorders.
• Characterised by the presence of two or more distinct identities or
personality states
• The identities or personality states ,sometimes called alters ,self ,states
and others each presents as having its own pattern of perceiving ,relating
to and thinking about the environment and self.
• Until about 1800,patients with DID were mainly seen as suffering from
various states of possession .
• In the early 1800s Benjamin rush built on the clinical reports of others
and provided a clinical description of DID,
• Pierre Janet described the symptoms of the disorder and recognised the
dissociative nature of symptoms
• Sigmoid Freud considered the symptoms to be reflective of schizophrenia.
 EPIDEMIOLOGY

• Clinical studies report female to male ratio between 5to 1 and 9 to 1 for
diagnosed cases
• Prevalence is around 1% in the community based studies
• Has a population prevalence comparable with that of schizophrenia.
 COMORBIDITY

• PTSD 79 to 98%- intrusive symptoms ,hyper arousal ,avoidance

• depression 83 to 96%-
• substance abuse 83 to 96%
• somatoform disorders 35-61%
• conversion disorders
• borderline personality disorders 31 to 83 %
• Suicidal thoughts and attempts of sself mutilation
• Obsessive compulsive symptoms
• Irritable bowel syndrome
• Gastro oesophageal reflux disease
• Seizure like episodes
 RISK FACTORS

• Childhood sexual abuse 83%

• Childhood physical abuse 81%
• Childhood trauma of any type 94%
• Available data suggests that the abuse was early ,extensive and prolonged
 PATHOGENESIS

• Dissociative identity disorder (DID) is a controversial diagnosis.

• Its pathogenesis is not known.
• Conceptual models for the development of DID include a trauma model,
supported by evidence on the association between a history of severe
childhood trauma and dissociative symptoms, and a sociocognitive model.
 TRAUMA MODEL
• This conceptualization is based on a stress-diathesis model.
• It formulates certain illnesses as occurring in individuals with a
predisposition to the illness who experience a significant “stress”, which
can be an environmental factor or a life event.
• Predisposing factors proposed in DID include a person’s inborn tendency
to dissociate, known as “dissociativity”.
• The primary stressors giving rise to DID in patients with high
dissociativity are believed to be sexual abuse, physical abuse, or other
severe trauma occurring during childhood
 CHILDHOOD TRAUMA
• The most commonly reported “stress” postulated in this model is a history
of severe childhood physical or sexual abuse, or other severe trauma.
 POOR INFANT ATTACHMENT

• Poor mother-infant attachment has been postulated as an additional factor

that may lead to DID in predisposed individuals.
• Two longitudinal studies described cohorts of 168 and 56 poor, high-risk
children who had been referred for social service intervention during
infancy and who were followed through age 19.
•
• Both studies found that the quality of the infant-mother attachment, as
measured in the first two years of life, was a stronger predictor of self-
reported dissociative experiences in late adolescence than was childhood
trauma.
• Neither study evaluated participants for the presence of a dissociative
disorder
 CLINICAL MANIFESTATIONS

• Identity — Distinct personality states in DID are reported to be

experienced by the patient, and sometimes by others, as having markedly
different characteristics, for example, different ages, genders, sexual
orientation, and abilities.
• Reports have suggested that the original personality state often constitutes
the dominant presence
• In people with DID, individual personality states have been reported to be
associated with traumatic experiences, as well as with specific mood
states, roles, or behaviours, for example:
• A terrified, crying child
• An angry, persecutory figure
• A state that feels impervious to physical pain
• A state that is calm, detached, and helpful to the therapist
• A state that is chronically suicidal
• Some clinician researchers have suggested that DID is better
conceptualized as a fragmentation of identity, with discontinuities in
memory experienced by the patient as intrusions into consciousness, rather
than as “switching” among distinct personalities
• Amnesia — Individuals with DID experience recurrent episodes of
amnesia.
• Patients typically report that they have periods of time (most often hours)
that they cannot remember.
• From secondary reports, these periods may be associated with certain
mood states or behaviours (eg, angry outbursts).
• Depersonalization — Depersonalization is a feeling of detachment or
estrangement from one’s self, for example, feeling outside of one’s body,
or that one is observing oneself from the outside.
• Derealization — Derealization is a feeling that the external world is
strange or unreal.
• Auditory hallucinations — Many individuals with DID report hearing
voices, for example, a voice giving suggestions or commands.
• Auditory hallucinations in DID have been described as chronic and
typically present since childhood .
• Dissociation can present with other first-rank or psychotic symptoms.
• Self-alteration — Self-alteration is the sense that one part of one’s self is
markedly different from another part of one’s self.
• Trance state — A dissociative trance state involves a narrowing of
awareness of one’s immediate surroundings or stereotyped behaviours or
movements that are experienced as being beyond one's control
• Somatoform symptoms — Somatoform symptoms are physical symptoms
that suggest a general medical illness that cannot be explained by a
presence of a general medical condition, substance use, or other mental
disorder.
• COURSE — While there are case reports and case series describing
patients with dissociative identity disorder (DID), there are no systematic,
prospective longitudinal studies providing data on the course of the
disorder. DID appears to have a fluctuating, typically chronic course, with
periods of higher and lower severity of symptoms and functional
impairment .
• Most patients with DID have reported that symptoms of the disorder first
appeared during childhood. Four studies including 199 patients reported a
mean age of onset between 5 and 7.8 years old..
 DIAGNOSIS

• The key feature in diagnosing this disorder is the presence of two or more
distinct personality traits
• However there are many other symptoms that define the disorder and
because of great diversity this makes the diagnosis difficult
•
 Mental status

• A careful and detailed mental status is essential in making the diagnosis

• It is easy to mistake patients with disorder as suffering from
schizophrenia, borderline personality disorder and malingering
 DSM -5
A. Disruption of identity characterised by two or more distinct personality
states ,which may be described in some cultures as an experience of
possession ,the disruption in identity involves marked discontinuity in
sense of self and sense of agency ,accompanied by related alterations in
affect , behaviour ,consciousness, memory ,perception ,cognition and /or
sensory –motor functioning .
B. Recurrent gaps in the recall of everyday events , important personal
information ,and /or traumatic events that are inconsistent with ordinary
forgetting.
C. The symptoms cause clinically significant distress or impairment in social ,
occupational or other areas of functioning
D. The disturbance is not a normal part of a broadly accepted cultural or religious
practice
Note : in children ,the symptoms are not better explained by imaginary play
mates or other fantasy play
E. The symptoms are not attributable to the physiological effects of a substance (
e.g blackouts or chaotic behaviour during alcohol intoxication ) or another medical
condition (e.g complex partial seizure )
• DID can be difficult to detect. Patients diagnosed with DID have been
reported in several studies to have received mental health care for an
average of seven years prior to being diagnosed with the disorder
• Several factors can make diagnosis of DID difficult, including:
• Patients infrequently present with clearly visible switching among distinct
personality states, and this presentation can be difficult to discern .
• Patients later diagnosed with DID more commonly first present with other
dissociative symptoms.
• Some patients experiencing dissociation may not be able to articulate their
internal state in a coherent way, describing baffling experiences such as “losing
time” or not remembering behaviour with others, who have described activities
they have shared. Others may describe altered behaviour:
• “Sometimes I act so strangely, I don’t understand it. It doesn’t seem like it’s me.”
• “Sometimes people tell me I act totally differently”
• Warnings from a perpetrator of childhood abuse to keep the experience a
secret may lead a traumatized patient to not disclose symptoms associated
with abuse.
• This may be particularly common on initial evaluation or early in
treatment, when the patient does not know and trust the clinician.
• High rates of comorbidity associated with DID can lead patients to present
for treatment emphasizing symptoms leading to other psychiatric
diagnoses, such as depression, chaotic interpersonal relations, and
somatoform symptoms.
• A diagnostic assessment of possible DID thus typically begins with the
identification of amnesia and evaluation for other dissociative symptoms
characteristic of the disorder, including depersonalization, derealization,
auditory hallucinations, self-alteration, trance states, and somatoform
symptoms.
 DIFFERENTIAL DIAGNOSIS

• Factitious disorder and malingering — A factitious disorder is diagnosed

when the patient intentionally feigns medical or psychiatric symptoms for
the purpose of assuming the sick role eg, receiving caretaking or
sympathy).
• Malingering adds to this presentation the purpose of achieving some
specific external advantage, such as a disability income or avoiding work
responsibility.
• Features of the presentation that can help identify factitious disorder or
malingering, distinguishing them from DID, include
• The presence of an obvious benefit of the symptoms to the patient
• A patient’s high degree of attention seeking, including flaunting symptoms
of DID Patients who have DID do not typically display symptoms
ostentatiously or seem enthusiastic about discussing them
• The presence of well-known symptoms of DID (switches to different
personality states and amnesia) in the absence of other, lesser known
dissociative symptoms
• General medical conditions — Amnesia can be caused by general medical
conditions, including various forms of dementia, and epileptic seizures.
• Patients should undergo a medical history and physical exam prior to a diagnosis
of DID. Based on the findings, more extensive evaluation may be needed.
• An observation which often proves helpful in distinguishing dissociative amnesia
from amnesia due to medical causes is that a patient with dissociative amnesia
will generally perform adequately on cognitive testing.
• He or she will likely demonstrate a well-preserved fund of general
knowledge, but exhibit specific deficits for autobiographical information.
Patients with dementia or other organic amnesias will usually show the
reverse, with autobiographical information preserved even as other
memory deficits worsen. )
• Posttraumatic stress disorder — Posttraumatic stress disorder (PTSD) and
DID have been found to frequently co-occur and share a history of
childhood physical and sexual abuse in many cases .
• PTSD is distinguished from DID by the presence of multiple symptoms
of re-experiencing, avoidance, and hyper arousal, where DID alone
requires the presence of amnesia and multiple personality states.
• A dissociative subtype of PTSD shares prominent symptoms of amnesia
and numbing with DID .
• Borderline personality disorder — Borderline personality disorder and
DID have been found to frequently co-occur and share a history of
childhood physical and sexual abuse in many cases .
• The identity disturbance which is a criterion for borderline personality
falls short of the severe fragmentation of identity, with amnesia between
personality states, found in DID.
• Schizophrenia — Auditory hallucinations and other first rank symptoms
of psychosis are shared by DID and schizophrenia .
• Auditory hallucinations in DID are typically highly personified, ie, related
to a particular identity state, and are usually experienced as a voice inside
rather than outside the head.
• Patients with DID have generally reported hearing voices beginning in
childhood and while the disorder causes distress or functional impairment,
the course typically fluctuates over time
• . In contrast, patients with schizophrenia typically experience
hallucinations in concert with other psychotic symptoms such as
disordered thinking, a flat affect, and pervasive deterioration in
functioning beginning in their late teens to early twenties
• Bipolar disorder — Changes in mood caused by switching of personality
status in DID can present as depression or can have characteristics of
mania, such as hyper sexuality or aggression
• DID is the more likely diagnosis if these mood states do not last more
than a few hours and begin and end abruptly, often in response to
environmental stimuli.
• A bipolar patient typically does not switch from depression to mania in a
few seconds, but this would be characteristic of behavioural state changes
occurring in DID.
• Intoxication — Intoxication with alcohol or benzodiazepines can lead to
episodes of amnesia [. Cannabis, hallucinogens and ecstasy have been
found to induce depersonalization .
• A thorough assessment of a patient’s substance use, abuse, and
dependence can help to differentiate these causes of dissociation from DID
 TREATMENT

• Appropriate treatment of the dissociative identity disorder patient follows

a phasic model that is the current standard of care for posttraumatic
disorders. The phases include
• (1) a phase of symptom stabilization;
• (2) an optional phase of focused, in-depth attention to traumatic material;
and
• (3) a phase of integration or reintegration in which the dissociative identity
disorder patient moves more completely away from a life adaptation based
on chronic traumatization and victimization
• Stabilization of the dissociative identity disorder patient is vital to permit
more successful negotiation of all aspects of treatment.
• Stabilization focuses on safety, stability, and management of core
dissociative identity disorder and comorbid symptoms.
• The vast majority of dissociative identity disorder patients engage in some
form of self-destructive behaviour, including suicide attempts, self-
mutilation, eating disorders, substance abuse, promiscuity, risk-taking
activities, and involvement in abusive, violence-based relationships.
• In general, cognitive and behavioural approaches are used, framing these
behaviours as part of a set of quasi-addictive, trauma-related, homeostatic
mechanisms. Experienced clinicians find that many dissociative identity
disorder patients can bring self-destructive and high-risk behaviours under
control
• Assessment of available family and community supports is also important.
• Successful psychotherapy for the dissociative identity disorder patient
requires the clinician to be comfortable with a range of psychotherapeutic
interventions and a willingness to actively work to structure the treatment.
• Many dissociative identity disorder patients are not able to stabilize
symptoms in the long term if the alter identities who control these
symptoms are not therapeutically engaged.
• Clinicians new to dissociative identity disorder are frequently
uncomfortable or perplexed by the need to work with individual alters and
how to do this without producing a chaotic regression.
• Certain basic principles are important to understand.
• No alter is any more or less real than any other alter or more good or bad
than another.
• All are aspects of a single human being and have adaptive, psychological
importance that needs to be heard and respected.
• All alters are held accountable and responsible for the behaviour of any part,
even if experienced with amnesia or lack of subjective ownership
• Educative interventions help decrease anxiety about symptoms that are often
frightening and overwhelming, build a therapeutic alliance, and provide
information that is the basis for a meaningful consent for treatment.
• Furthermore, it is necessary to educate the patient about the contentious and
divisive debates that surround the diagnosis and treatment of dissociative identity
disorder in contemporary psychiatry and psychology.
• The patient should be counselled that symptomatic worsening may occur
during treatment, particularly during phases in which memory material is
worked with in depth (second phase of treatment)
• Clinicians working with dissociative identity disorder patients should
avoid boundary changes that make the patient “special,” even if the patient
insists that only these interventions will help.
• These include holding or hugging the patient, holding the patient's hand,
accepting more than a token gift such as a card or a small piece of artwork,
giving the patient gifts, phoning the patient while on vacation, and going
for walks or other out-of-office contacts with the patient, among many
others.
• Dissociative identity disorder patients may experience a multitude of
cognitive errors and distortions based on traumatic life experiences and the
ability of dissociation to interfere with reality testing.
• Typical cognitive distortions include (but are hardly limited to)
• The insistence that alters inhabit separate bodies and are unaffected by the
actions of one another (delusional separateness), that the patient is helpless
to control himself or herself and requires the clinician to manage all
difficulties, that the clinician is completely untrustworthy and must not be
allowed any access to the patient's mind, that the patient is bad and
deserved or caused childhood sexual abuse to occur, that anger and
violence are the same, that love and sex are the same and so on
• Behind these cognitive distortions frequently lie exceptionally painful
realizations and recollections
• Dissociative identity disorder patients often manifest a complex multilayered
transference as a whole, as a system of personality states, and as individual
alter personality states.
• Countertransference responses may vary as well, with overinvolvement,
detached hostile skepticism, or a sense of being exasperated, overwhelmed,
and deskilled being quite common. C
• For patients who can stabilize and form a reasonable working alliance in
treatment, longer-term treatment goals involve the detailed, affectively
intense, psychotherapeutic processing of life experiences, especially
traumatic experiences, and the transformation of the meaning of these
experiences for the individual.
• in most cases, intensive, detailed psychotherapeutic work with traumatic
memories should only be initiated after the patient has demonstrated the
ability to use symptom management skills independently, after the alter
identity system can work together in a reasonably cooperative way, and
after a solid therapeutic relationship has been established
• Potential risks may include acute worsening of PTSD, affective, somatoform,
and self-destructive symptoms and short-term interference with daily activities.
• Long-term benefits may include significant amelioration of dissociative and
PTSD symptoms, decreases in subjective self-division, fusion of alter identities,
and freeing of psychological energy for daily life.
• The patient must be able to understand that the goal is integration of dissociated
thoughts, feelings, recollections, and perceptions, not the exhumation of
memories per se.
• Third Phase: Fusion, Integration, Resolution, and Recovery
• Over the course of treatment, significant unification of dissociated mental
processes may be observed.
• Alters lose distinctness and decrease compartmentalization of thoughts,
memories, and affects.
• The patient develops a more unified sense of self.
• Transference is modified consistent with these changes.
• Amnesia and switching become less apparent.
• Fusion of alters results in psychological merging of two or more entities at
a point in time, with a subjective experience of loss of all separateness.
• The term integration is sometimes used synonymously with fusion but is
more generally defined as the process of undoing all forms of dissociative
division during treatment. Some patients
• Proceed to what appears to be a complete fusion of all alters, with a shift
in self-representation from that of a dissociative
•
Identity disorder individual to one with a consistent and continuous sense
of self across all behavioural states.
• Many patients never attain a complete fusion of their alter personalities
but leave treatment when they have achieved a therapeutic resolution:
Relative stability, adequate function, and some measure of internal
harmony among self states.
• As this integrative process occurs, PTSD symptoms usually improve
significantly.
• Patients often experience a freeing of energy toward everyday life and
away from trauma-focused ways of living.
• Cognitive distortions frequently substantially subside. At the same time,
non dissociative and integrative coping strategies must be identified and
substituted for dissociative responses to life stressors.
• Losses must be mourned, and the patient must be helped to connect and
cope with the larger world in a more functional manner.
 HYPNOSIS
• Despite the controversy about its use, hypnosis was endorsed by approximately
two-thirds of respondents as a psychotherapeutic adjunct in dissociative identity
disorder treatment.
• Hypnotherapeutic interventions can often alleviate self-destructive impulses or
reduce symptoms, such as flashbacks, dissociative hallucinations, and passive-
influence experiences.
• Teaching the patient self-hypnosis may help with crises outside of sessions.
Hypnosis may be useful for accessing specific alter personality states and their
sequestered affects and memories.
• Hypnosis is also used to create relaxed mental states in which negative life
events can be examined without overwhelming anxiety.
• Clinicians using hypnosis should be trained in its use in general and in
trauma populations.
• Clinicians should be aware of current controversies over the impact of
hypnosis on accurate reporting of recollections and should use appropriate
informed consent for its use
 PSYCHOPHARMACOLOGICAL
INTERVENTIONS
• Antidepressant medications are often important in the reduction of
depression and stabilisation of mood
• PTSD symptoms like intrusive and hyper arousal symptoms are
particularly medication responsive
• SSRI, tricyclic ,and MAO antidepressants anticonvulsants and
benzodiazepines reduce intrusive symptoms ,hyper arousal and anxiety in
patients with DID
• Case reports suggest that aggression may respond to carbamazepine in
some individuals
• Atypical neuroleptics such as risperidone and olanzapine might be more
effective and better tolerated than typical neuroleptics for overwhelming
anxiety and intrusive PTSD symptoms
• An extremely disorganised overwhelmed , chronically ill patient with
DID who has not responded to trials of other neuroleptics ,respond
favourably to a trial of clozapine
 ELECTROCONVULSIVE THERAPY
• For some patients ameliorates refractory mood symptoms and does not
worsen dissociative memory problems
 ADJUNCTIVE TREATMENTS
• GROUP THERAPY – reported to be more succeful
• Groups must be carefully structured ,must provide firm limits and
generally focus on only on here and now issues of coping and adaptation
• Family therapy – important for long term stabilisation and to address
pathological family and marital process
• Education of family and concerned others about the disorder and its
treatment may help family members cope
• Expressive and occupational therapy's- art and movement therapy have
proved particularly helpful in treatment of patients with this disorder
• permits patients safer expression of thoughts ,feelings , mental images
and conflicts that they have difficulty verbalizing .
• Occupational therapy may help the patient with focused ,structural
activities that can be completed successfully and may help with grounding
and symptom management .